Abstract: On or about March 10, 1995, Employee #2, a welder, was part of a four-person crew whose assigned task was to install the sides on rail cars. A 15 ton crane is used to position the 3,500 lb steel car sides for welding. Before the crane is released, the sides are wedged at the bottom and secured at the top with a chain attached to the center and side structural member. Two of the crew then spot weld the side in place. The other two men are assigned to the horse shoe, a piece of equipment which encapsulates the sides and top of the car and is equipped with pneumatic rams and a work platform "basket." The horse shoe is placed at the end of the car and the rams clamp the sides and remove the air gap. The welders work from a platform on the inside of the car. Employee #2 was operating the crane. He positioned one side and, with the help of a coworker, placed wedges on the bottom. The crane was left connected because Employee #2 thought the crane was not needed elsewhere at the time, and the spot welding could be completed. Employee #1, the supervisor, had been in the area helping, and Employee #3, the shop superintendent, came over to discuss a problem with the location of one of the spot welds. Employee #2 observed an employee from Main Fit approach Employee #1 and say something. Employee #1 turned and asked Employee #2 if he was finished with the crane. Employee #2 replied that he was, except for installing chains at the top of the car side, and he turned away. A short time later he observed the Main Fit employee climbing the ladder and removing the clamps from the car side. Later, Employee #2, returning from the Main Fit area, observed the top of the side move as if it were falling. He yelled and ran to push Employee #1 out of the way. As the side fell, it caught Employee #1, who was kneeling, and also struck Employees #2 and #3. Employee #1 was killed and Employees #2 and #3 were seriously injured. Employee #2 required hospitalization. Company operating instructions and procedures were not followed in that the crane was disconnected from the load, by an untrained employee, from another department, prior to the installation of chains to secure the load in place. This condition was the direct cause of the accident.